treating sleep disorders: what it means for preventive medicine joseph m. holshoe, pmhnp-bc...
TRANSCRIPT
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Treating Sleep Disorders: What It Means For Preventive Medicine
Joseph M. Holshoe, PMHNP-BCCommander, U.S. Public Health Service
Behavioral Health Consultant, Primary Care ClinicNaval Health Center New England
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Naval Health Center New England
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WWSS
“To sleep, perchance to dream
Aye, there’s the rub”
Hamlet, W.Shakespeare
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Prevalence & Cost of Lost Sleep
• Prevalence– 6-30% general
population– 80-90% psychiatric
population– 50-70 million Americans
• Gender – more common in women
• Age – elderly report more problems sleeping
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Prevalance (Cont’d)
• 20% of U.S population self –medicate with OTC’s
• 40% self-medicate with ETOH
• 30% of Americans are short-sleeping
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Costs of Decreased Sleep
Societal Costs• $100 Billion in lost productivity (2005)• School performance impairment• Personal & social distress ($?)
Healthcare Costs• Estimated healthcare costs: 75% greater!
• Increased healthcare visits• Chronic disease• injury
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Healthcare Effects of Impaired Sleep
– Obesity– Hypertension– Metabolic syndrome– Heart disease– Depression & Mood
disorders – Decreased life-
expectancy– Increased injury &
accidents– Impaired immune function– increased utilization of
healthcare resources
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Immediate Effects of Insomnia
• Impaired concentration
• Depressed mood & irritability
• Malaise & fatigue
• Muscle pain
• Increased sensitivity to pain
• GI complaints
• Appetite changes – carb cravings?
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Most Common Effect: Irritability
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Sleep Across the Life Span
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Sleep Across the Lifespan
• Newborns & Infants may sleep up to 23-24 hours a day. Lots of REM sleep.
• Children require 10-12 hours of sleep• Teens require 9-10 hours of sleep (rarely get it)
and fall asleep later in the evenings than adults (Sleep Phase Delay)
• Adults require about 7-8 hours of sleep• Elderly have decreased deep sleep and more
fractured sleep and often fall sleep earlier and wake earlier (Sleep Phase Advance)
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Teenagers
• Sleep-Phase Delay• Night Owls• Early Morning Light
Exposure- use with caution!
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Older Adults
• Sleep-Phase Advance– Late afternoon light
exposure
• Poor Sleep Continuity• Frequent complaints
of insomnia
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The Evolution of Sleep
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What is Sleep?
• “Alteration in consciousness”
• Essential for life
• Distinct brain functions– REM & Non-REM– Active & Inactive states– 90 minute cycles
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Stages of Sleep
Non-REM SleepNon-REM Sleep
• Deep Sleep • Each stage
progressively deeper• Growth hormone
release• Deepest early in the
sleep cycle
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Stages of Sleep
•REM sleepREM sleep
•““Active” sleep
•Most prominent in late morning
•Dream sleep associated with consolidation of memory
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Mechanisms of Sleep
• Homeostasis
• Circadian Rhythms
• Arousal
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Homeostasis
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Sleep Pressure
• Sleep pressure is cumulative in the short-term
• Long-term sleep deprivation appears to activate adrenergic system
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Circadian Rhythm
• Internal Clock – 24.5 hour cycle– Light & Hormone-mediated
• Time, length & intensity of light exposure
– Core body temperature• Temperature nadir
– Lark vs. Night Owl• Sleep phase advance/delay
– Hormone cascade• Melatonin, adenosine …..
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Arousal
• Yeah, baby!
• Length of time awake
• Stimulants
• Light Exposure– “Blue Light Special”
• Exercise
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Sleep occurs when …
• Sleep drive surpasses the arousal drive (homeostasis)
• Inner clock recognizes time for sleep (Circadian Rhythm)
• Individual arousal characteristics are decreased (Arousal)
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Sleep Disorders
• Primary Sleep Disorders– Primary Insomnia– Sleep Apnea– Restless Leg/Periodic Limb Movement– Narcolepsy– Parasomnias
• Secondary Sleep Disorders– COPD, CHF– Depression
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What is Insomnia?• Inability to initiate or maintain restful sleep
– Functional sequela – 3-5 days per week
• Symptom & Syndrome?
• Precipitant– Precipitant may leave but insomnia remains
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Sleep Hygiene: What is It?
• Behaviors to decrease arousal
• Condition sleep response
• Increase sleep load
• Align circadian rhythms
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Sleep Hygiene: Decreasing Arousal
• Bed only for sleep & sex• Avoid noise, temp extremes, bright lights• No caffeine after 3pm• Exercise regularly but not later than 5-6 hours
before bedtime• No TV or computer in bed• Keep bedroom cool and dark• Light carbo snack• Create “worry period” – away from bedroom
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Sleep Hygiene: Conditioning
• Goal: Condition bedtime with positive sleep emotions/response– Maintain regular bedtime and awakening time,
even on weekends– Incorporate relaxing rituals into bedtime– Do not remain in bed longer than 10-15
minutes if unable to sleep– Bed only for sleep & sex– Break anxiety cycle related to sleep
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Sleep Hygiene: Increase Sleep Load
• Avoid early bedtimes following a bad night’s sleep– Sleep restriction
• Increase day-time sunlight exposure
• Exercise
• Avoid napping
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Sleep Hygiene: Circadian Rhythms
• Regular bed-time and awakenings
• Properly timed sun-light exposure
• Regular meal schedules
• Avoid naps
• Lark or Night owl
• Medications
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Why Avoid Alcohol?
• Alcohol increases desire to sleep but fragments sleep architecture & increases total REM exposure
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Joe’s Theory of Sleep Hygiene
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Rx for Insomina
• Non-Benzo Sleep Hypnotics– Zolpidem (Ambien)
• Parasomnias• Long-term use data
– Eszopiclone (Lunesta)• Metallic taste• May enhance antidepressants
– Zaleplon (Sonata)• May enhance antidepressants
– Ramelteon (Rozerem)• M 1-2 agonist• 7-10 day delay in response
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Rx for Insomnia
• Benzo’s– Temazepem (Restoril)– Triazolam (Halcion)– Lorazapem (Ativan)– Clonzapem (Klonipin)
• Enhances sleep cycles
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Issues with Benzo’s + Non-Benzo’s
• Addiction potential– No addictive behaviors
seen with non-benzo’s
• Fall Risk – Elderly?• PTSD – Impairs Fear
Extinction• Tolerance
– Tolerance not identified with non-benzo’s
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Antidepressants and Sleep
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SSRI’s & SNRI’s
• REM suppression but decreased REM latency
• Significant sleep architecture disturbance
• “sedation” is not equivalent to restful sleep
• Yet, patients’ report more restful sleep?
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Antidepressants and Sleep
• SSRI’s
– Escitalopram
• SARI’s
– Trazodone *
– Serzone
• TCA’s
– Amitriptyline
– Doxepin
• Atypical’s
– Buproprion *
– Mirtzapine
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New Antidepressant for Sleep?
• Agomelatine
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Other Meds
• 1st generation anti-pyschotics– Enhance sleep but
worth the risk of EPS?
• 2nd generation anti-psychotics– Enhance sleep but
metabolic risks?
• Gabapentin (Neurontin)
• Lamotrigene (Lamictal)
• Pregablin (Lyrca)
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OTC’s & Herbals
• Histamines– Residual sedation– Side-effects from anti-cholinergic
• Valerian
• Kava Kava
• Melatonin– Dose-curve response– Circadian re-set– Jet-lag, shift work
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Issues in Treating Sleep
• Sleep Hangover?• Rebound Insomnia?• Sedation?
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Questions?